Re: [ozmidwifery] Clexane

[Marilyn Kleidon]

Title: Clexane

Hi Justine and all:   I tried real hard to let this alone a wait for a while but just couldn't. I do think that a homebirth could be possibly contraindicated for this woman because of these cardiolipin antibodies coupled with her apparently needing anticoagulation theraapy. I have done a Pubmed search and googled and I think the results support my inclination. Elevated cardiolipin antibodies can be associated with a number of autoimmune disorders including autoimmune thrombocytopenia, antiphospolipid syndrome, systemic lupus, haemolytic anemia, non-traumatic thrombosis, and prior exposure to treponemal organisms (like syphilis and lyme disease to name a couple).  They are associated (note, not  causal) strongly with increased fetal damage and loss, thrombosis, stroke, PIH, IUGR and so on whcih is why a homebirth could be contraindicated. Treatment throughout pregnancy does involve close monitoring of various antibodies (not just the cardiolipin) and possible adjustments to the anticoagulant therapy. This I believe would necessitated care with an obstetrician or perinatologist competent and confident in this area apparently new research is happening all the time. There is a strong association with infertility research. It is also possible that this woman's condition maybe relatively benign (such as if she had a prior exposure to the infectious agents mentioned or just one of the otherwise healthy people with elevated levels)  but only a thorough differential diagnosis and assessment would tease this out. None of this contraindicates concurrent 1-2-1 midwifery care which I believe would be essential for this woman. I have pasted below some info from a research site from the google search (search terms: "cardiolipin antibodies" AND pregnancy). As with just about everything these days there is controversy surrounding the various treatments.   I hope this helps.   marilyn   Antigen: Cardiolipin is not, like most other autoantigens, a protein, but a phospholipid. Phospholipids are major components of membranes of living cells and of organelles within these cells. Cardiolipin is located in bacterial membranes, mitochondria, and chloroplasts. Cardiolipin is made up of two phosphatidic acid groups, each attached to a glyceride moiety by a phosphodiester bond, and joined by a central glycerol moiety. Antibodies bind to the complex of cardiolipin and the cofactor ß2-GPI. Pharmacia assays are coated with purified cardiolipin. Antibody specificity and prevalence: - Antiphospholipid syndrome (APS) (one of two laboratory criteria for the diagnosis of APS) - Stroke (7%), stroke in young patients (18%) - Pregnancy loss*: 3 or more consecutive pregnancy losses (15%), in 2nd or 3rd trimester (30%), with growth retardation and late loss (40%) - Secondary APS in SLE (10-15%) - Connective tissue diseases like SLE (44%), RA (4-49%), Scleroderma (25%), juvenile chronic arthritis (42%) (numbers of secondary APS included) - Infectious diseases like Lyme disease (32%), syphilis (75%), leprosy (67%), tuberculosis (53%) and some more (Q fever, AIDS) - Epilepsy (11%) - Healthy individuals (0-7.5%) *numbers refer to antiphospholipid antibodies in general Disease activity: High aCL levels are associated with increasing risk for thrombosis or fetal loss. Raised anticardiolipin antibody levels may be detected many years prior to the _expression_ of thrombosis or fetal loss. The risk for fetal loss increases from 6.5% (aCL negative) to 15.8% with aCL positivity. When is the measurement recommended? - Suspicion of antiphospholipid syndrome - Fetal loss - Stroke in young patients - Unexplained thrombosis - in discussion: migraine, epilepsy, chorea, heart valve disease, skin ulcers etc. Antibody isotypes: IgG is accepted as the most frequent and most important isotype in aCL detection but the measurement of IgM and IgA is recommended, too, otherwise some risk patients would be lost. The clinical association of different aCL isotypes is discussed controversially in the literature. References: Moris V, Mackworth-Young C (1996) Autoantibodies to phospholipids. In: Van Venrooij WJ, Maine RN (eds.) Manual of biological markers of disease, Kluwer Academic Publishers, Dordrecht Khamashta MA, Hughes GRV (1996) Phospholipid Autoantibodies - Cardiolipin. In: Peter JB, Shoenfeld Y (eds.) Autoantibodies, pp 624-629, Elsevier, Amsterdam Roubey RA (1999) Immunology of the antiphospholipid syndrome: antibodies, antigens, and autoimmune response. Thromb Haemost 82: 656-661 ----- Original Message ----- From: Justine Caines To: OzMid List Sent: Monday, December 20, 2004 8:51 PM Subject: [ozmidwifery] Clexane Dear All The message below came to me through the Homebirth Australia website. I would really appreciate your clinical wisdom Justine I had a homebirth with my first child in the UK in 2001.I would dearly like to have another homebirth here in Australia but I now have Cardiolipin antibodies and have to inject myself daily with Clexane as well as taking low dose asprin. I was wondering if this would affect my choice of birth? If you are able to help me or offer some advice or let me know who may be able to help me I would be very grateful